Psychiatric Chronification

David Mintz, MD, authored "Psychiatric Chronification" in Psychiatric News.

This article was republished with permission from Psychiatric News © 2025

Psychological factors may play an important role in pharmacologic treatment resistance, as when the patient’s ambivalence about medications, caregiving authority, or health itself undermines treatment engagement and treatment effectiveness. We can think of this kind of treatment resistance as “treatment resistance to medications.” This may be contrasted with “treatment resistance from medications” (Mintz, Psychodynamic Psychopharmacology, 2022), where ostensibly helpful pharmacotherapy paradoxically perpetuates patienthood through mechanisms that are largely psychological. In contrast with patients who are treatment-resistant to medications, patients who are treatment-resistant from medications typically desire medications, report them to be helpful, and often want more. However, while such patients feel better, they do not get better. A related phenomenon has been identified in neurology, where complex bio-psycho-social processes transform short-term benefits of treatment into pain chronification. One sign of psychiatric chronification is a countertransference unease where, despite the patient’s reports of improvement (and even evidence of improvement on symptom scales), the psychiatrist feels reluctant to prescribe. There is a feeling of participating in something vaguely perverse, and one senses that the patient is in the process of becoming a chronic patient. Such processes driving psychiatric chronification are among the thorniest, most complicated, and most painful parts of psychiatric practice. At the same time, this is also one of the least discussed and researched problems that we face.

Most straightforward is when patients misuse medications recreationally, rather than for health. Such patients will continue being patients as long as medications directly serve dopamine reward systems—unless the psychiatrist refuses to participate. The prescriber’s impulse is often, usefully, to deprescribe. The dynamics of psychiatric chronification are often more complex, when medications are helpful on another level, but they (or their meanings) also serve defensive functions that interfere with the patients’ agency and development. Medications used to avoid self-awareness and personal responsibility: Medications may serve as “inexact interpretations” (Glover, 1931), with medical explanations defending against burdens of responsibility, undercutting agency and self-efficacy. Most psychiatrists will have encountered the impulsive, labile character who tenaciously holds to a past bipolar diagnosis. In this case, the diagnosis comes to mean: “I am not responsible for my unhealthy behaviors,” relieving the patient of their terrible guilt and shame. While this patient feels immediately better, they often get worse, as they assign responsibility for their destructive behaviors to the doctor, giving their impulses free rein.

Medications used to deny reality and avoid healthy developmental steps: Another patient, depressed and anxious, is in an abusive relationship. She is prescribed an SSRI and a twice-daily low-dose benzodiazepine, the latter of which she instead takes in a double dose at 4 p.m., just before her abusive boyfriend gets home from work. In this way, she can exist in a medically induced dissociation, allowing her to bear this abusive situation. This patient, too, seems unlikely ever to become non-depressed as long as she uses the medications to avoid facing reality and taking healthy developmental steps to put an end to the abuse.

Overreliance on medications deskills the patient: Another patient, subject to intense and reactive mood swings, has used a sedating antipsychotic to manage intense dysregulation since her teens. As a young adult, she uses her second-generation antipsychotic helpfully three to four times a week for suicidal overwhelm, allowing her to sleep and wake feeling “reset.” However, while other adolescents were learning to manage upset with a range of more mature coping strategies, this patient was learning just one strategy, essentially rendering her a chronic patient, dependent on medications.

Medications replace people: Other patients, particularly those with early adversity, struggle to tolerate the vulnerability inherent in turning to others for support. Not uncommonly, such patients might prefer to turn to medications when in distress, which are more predictable than people. While this can be helpful in the moment, it functions as a defense against healthy interpersonal vulnerability and serves to depopulate the patient’s world. More isolated, the patient’s distress increases, reinforcing a turn toward medications. Now, potentially, the patient is in a vicious cycle of medicalized distress and isolation, potentially perpetuating patienthood. These are just some of the dynamics that might be encountered in the psychiatrist’s office that contribute to psychiatric chronification.

Deprescribing is not always the optimal response to chronification, particularly when there are concrete psychiatric benefits of the medication. It can be helpful to distinguish between countertherapeutic effects that are primarily biomedical versus those that emerge largely from the psychosocial level. In the latter case, psychiatric chronification may best be addressed at the level of meaning, in ways that empower the patient and reinforce growth (Mintz, Recovery from childhood, 2022). Because defensive uses of pharmacotherapy may decrease distress, patients may show improvement on symptom measures. Prescribers focusing narrowly on symptoms may see that the patient feels better but miss that they are not getting better, leading to an unwitting collusion with the patient’s defense. When pharmacotherapy is explicitly intended to support development, treatment resistance from medication may be more easily recognized. Having negotiated a focus on the promotion of health (as opposed to an absence of symptoms), it becomes easier for the prescriber to engage the patient about possibly countertherapeutic uses of treatment.

Meaning making as a psychiatric activity: Ordinary medical psychotherapy can be usefully integrated into pharmacotherapy. When patients use medications in ways that undermine their agency (e.g., defensively stripping feelings of meaning or projecting responsibility into pharmacotherapy), the prescriber could empathically explore, given the complicated interactions of meaning and biology, whether the patient has such a biologized (and possibly defensive) understanding of their troubles. If a solid alliance has developed and the prescriber has a clear idea about misuses of pharmacotherapy, these may be directly interpreted to the patient (Mintz, Recovery from childhood, 2022).

Using the alliance: Just as in psychotherapy, the alliance may be a fulcrum of effective pharmacotherapy. When medications are used in ways that disregard the agreement to use them in support of growth, the prescriber can notice that the terms of the treatment agreement seem unilaterally to have been changed. Identifying and exploring how breakdowns in the relationship may have occurred can help reestablish an alliance.

Supporting healthy strategies to replace countertherapeutic uses of medications: When medications have supplanted development (as in the case above), leading to the development of actual deficits, abrupt deprescribing may be inadvisable. Psychosocial remediation (emotional skills training or affect-focused psychodynamic therapy, etc.) may be needed to support a gradual medication taper, as the patient develops more mature coping skills. Perhaps it is time for this complicated and fairly ubiquitous problem, causing so many psychiatrists confusion, consternation, shame, and even moral injury, to come more into the center of our awareness, where it can be explored, learned about, and more effectively addressed. ■

Mintz D: Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient. Washington (DC): American Psychiatric Publishing; 2022. Glover E: The therapeutic effect of inexact interpretation: a contribution to the theory of suggestion. International Journal of Psychoanalysis 1931; 12(4):397-411. Mintz D: Recovery from childhood psychiatric treatment: addressing the meaning of medications. Psychodyn Psychiatry 2022; 50(1):131-148.